Provider Demographics
NPI:1528148483
Name:JACKSON, MELINDA MULLINS (M D)
Entity type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:MULLINS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:M D
Other - Prefix:DR
Other - First Name:MELINDA
Other - Middle Name:CHARLENE
Other - Last Name:MULLINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M D
Mailing Address - Street 1:4641 MAUREY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5625
Mailing Address - Country:US
Mailing Address - Phone:601-594-6006
Mailing Address - Fax:
Practice Address - Street 1:701 NORTHSIDE DRIVE
Practice Address - Street 2:CENTRAL MISSISSIPPI RESIDENTIAL CENTER
Practice Address - City:NEWTON
Practice Address - State:MS
Practice Address - Zip Code:36345-2361
Practice Address - Country:US
Practice Address - Phone:601-683-4200
Practice Address - Fax:601-683-4269
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11594207R00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018302Medicaid
MSA72126Medicare UPIN
MS00018302Medicaid